Ventricular assist device support in children: better, but not perfect

Abstract

Ventricular assist device (VAD) support of children as bridge to transplantation or recovery can be associated with major morbidity. In infants and small children, VAD support is especially challenging and restricted to para-corporeal devices. Additional anatomic, physiologic and access limitations, along with coagulation system immaturity, further increase VAD complications in these small children. In the current issue of the EJCTS, Rohde et al. reviewed the European Registry for Patients with Mechanical Circulatory Support database and identified 230 children who received the Berlin Heart EXCOR device between 2011 and 2021. They found that 46/230 (20%) had cerebrovascular accident (CVA) and that majority of these (71%) occurred within 90 days following VAD implantation. They also identified pump thrombosis and need for right VAD as risk factors for CVA [1]. In the original EXCOR study, reported CVA was 29% while transplantation was achieved in 88% of patients [2]. This was in a controlled trial setting with very strict selection criteria. When the follow-up extended study was published, 36% of children died and 55% reached transplantation [3]. Most importantly, CVA and multisystem organ failure were the most common reasons for death after VAD [4]. The clinical experience with the EXCOR device has since increased worldwide and the findings from Rohde are in line with other published reports in children [4, 5]. For example, a report from the Netherlands has shown that 50% of children had CVA, with 68% of those occurring in the first 30 days. Similarly, CVA was the most common cause of death [5]. While the study by Rohde examining a contemporary experience was unable to demonstrate an era impact on CVA occurrence, other reports seem to suggest a trend towards lower CVA rate in the recent era [1, 4, 6]. What can we attribute the improving trends to? Two factors seem to play a significant role: (i) the clinical status of the patient going into VAD implantation and (ii) potential improvements in early postoperative management.